Rural Health in the Final Report of the Commission on the Future of Health Care in Canada

In 2000, the Prime Minister appointed the Honourable Roy J. Romanow to review the current status of the health care system in Canada and to recommend policies and measures that are needed to ensure the sustainability of and to improve the system.

The Commission on the Future of Health Care in Canada completed its work in November 2002 and Mr. Romanow presented to the government and made public its final report titled Building on Values: The Future of Health Care in Canada.

The Commissioner has paid special attention to rural health issues. Titled Rural and Remoted Communities, Chapter 7 of the report is devoted to discussing health issues that are of concern to those living in rural and remote communities. In addition, a number of recommendations have been made with a view to addressing critical rural health issues.

The following is extracted from Building on Values: The Future of Health Care in Canada. It contains Chapter 7 in its entirety and sections and recommendations from other chapters.

CHAPTER 7: RURAL AND REMOTE COMMUNITIES

Directions for Change

Establish a new Rural and Remote Access Fund to support new approaches for delivering health care services and improve the health of people in rural and remote communities.

Use a portion of the Fund to address the demand for health care providers in these communities.

Expand telehealth to improve access to care.

The Case for Change

Given its geographic makeup, Canada faces unique challenges in the delivery of health care. The vastness of the Canadian landscape, combined with the fact that many Canadians live in isolated and remote communities, makes it difficult to ensure that all our citizens have access to health care services regardless of where they live.

Canada may, in fact, have a very good health care system with health outcomes that are generally among the best in the world. But there are growing signs that this is not the reality for Canadians living in smaller or more isolated communities across the country.

During the Commission’s consultations, Canadians living in rural and remote communities spoke directly about their serious concerns. They spoke of the need for good health and good access to health care not only because it is essential to sustain their own quality of life, but also the quality of life in their communities (CPRN 2001).

People’s choice of whether or not to live in smaller communities is affected by whether or not they can get reasonable access to health care (Association des régions du Québec 2002). That view was echoed by rural physicians who said, “geography is a determinant of health” (Society of Rural Physicians of Canada 2002).

Information on disparities in health confirms that view  geography is, in fact, a determinant of health. People in rural and remote communities have poorer health status than Canadians who live in larger centres. Access to health care also is a problem, not only because of distances, but because these communities struggle to attract and keep nurses, doctors and other health care providers.

Recommendations in other chapters of this report  to expand primary health care, expand coverage for home care and prescription drugs, or shorten waiting times  will have an impact on people in smaller communities. But the focus of this chapter is squarely on two pressing issues: improving health and improving access to health care for people in rural and remote communities.

Identifying the Issues

Using the Statistics Canada definition of “rural,” Figure 7.1 shows that there are wide variations in the proportion of rural to urban populations in each of the provinces and territories. The proportions range from just over 15% in British Columbia and Ontario to 68% in Nunavut. However, these proportions tell only part of the story. While the percentages in provinces like Ontario may be small, because of the size of the population, the numbers are actually quite large.

Rural Canada is not a single, homogeneous population. Diversity is a characteristic of Canada and it applies to smaller communities just as it does to the largest cities. Some rural communities are relatively close to major urban centres while others are not. Some are located in large agricultural regions, while others are coastal communities or located in the remotest regions of Canada’s north. Both the health needs and the way in which they should be addressed vary for different communities. As with many other issues in health care, there is no “one size fits all” solution.

While there are clear distinctions between “rural” and “remote” communities, to simplify the language in this chapter, the terms “rural” or “smaller communities” are occasionally used to refer to all types of rural and remote communities. Issues specific to these communities also overlap with Aboriginal health issues (addressed in more detail in Chapter 10) since many Aboriginal peoples live in smaller communities.

Rural communities may be diverse, but they share some common problems in health status, in access to health care, and in approaches that have typically been taken in the past to address those issues.

Disparities in Health

Health indicators have consistently shown that the health status of people living in rural communities, especially people in northern communities, is not as good as the rest of the Canadian population.

Statistics Canada and the Canadian Institute for Health Information (CIHI) developed health indicators for 139 health regions in Canada. They grouped health regions into three categories: predominantly urban, intermediate and predominantly rural (see Table 7.1). This information shows that:

Life expectancy for people in predominantly rural regions is less than the Canadian average;

Disability rates are higher in smaller communities;

Rates for accidents, poisoning and violence are also higher in smaller communities; and

People living in remote northern communities are the least healthy and have the lowest life and disability-free life expectancies.

The health of a community also appears to be inversely related to the remoteness of its location. In Quebec, for example, there is “a trend toward a progressive deterioration in health as one moves from [the] area bordering urban centres into the very remote hinterland” (Pampalon 1991, 359). The situation is similar in most other provinces and territories. In fact, these challenges are not unique to Canada. Other countries such as the United States, Australia, and even relatively small and compact countries like the United Kingdom, have similar challenges (Gamm et al. 2002; Humphreys et al. 1996; Braden and Beauregard 1994; Fearn 1987).

Disparities in Access to Health Care

Canadians in rural communities often have difficulty accessing primary health care and keeping health care providers in their communities, let alone accessing diagnostic services and other more advanced treatments. In some northern communities, the facilities are limited and in serious need of upgrading.

People in rural communities also have the added burden of paying for the high costs of travel in order to access the care they need. This often means days or weeks away from family and social support as well as the added cost of accommodation and meals.

In the 1990s, many provinces took steps to rationalize the delivery and administration of health care as part of health care reforms. As a result, some services were centralized into larger centres. Partly because of these changes, provincial and territorial ministries of health and regional health authorities have used a number of different approaches to improve access through outreach programs, financial assistance for people who need to travel to access care, and new delivery approaches like telehealth. These efforts, to greater or lesser degrees, have helped improve access. But the problem is far from solved. In fact, some would say that there is an “inverse care law” in operation. People in rural communities have poorer health status and greater needs for primary health care, yet they are not as well served and have more difficulty accessing health care services than people in urban centres.

Disparities in Access to Health Care Providers

Problems in access to health services quite often stem from serious shortages in health care providers in rural communities.

Access to physicians and specialists varies significantly across the country and some communities do not have access to even the most basic health care services because they lack the necessary health care providers. In 1993, there was less than one physician per 1,000 people in rural and small town areas, compared to two or more physicians per 1,000 people in larger urban centres. The average resident in rural communities and small towns was 10 km from a physician, compared to less than 2 km for a resident in larger urban centres (Ng et al. 1999).

In northern communities, the problems are stark. About 16,000 people live in the most northern part of Canada, at 65-69 degrees north latitude (northern parts of Yukon, Northwest Territories and Nunavut). About two-thirds of them live more than 100 km from a physician. And no physicians normally live above 70 degrees north latitude to serve the 3,300 people living there (Ng et al. 1999).

Given the shortages of nurses across the country, it is safe to assume the problems of recruiting and retaining nurses in smaller communities are serious indeed. According to the Canadian Health Services ResearchFoundation, “It’s not just a question of having a lot of people to work in the healthcare system; it’s also about making sure healthcare workers are well distributed through the provinces and among urban, rural and remote areas” (CHSRF 2002b, 3).

The problem of attracting health care providers to rural communities is exacerbated by competition among individual provinces and territories. Keeping health care providers in rural areas is an ongoing problem, and territories compete to attract and retain the supply of health care providers they need.

The problems with the supply of physicians in rural and remote communities demand solutions. But the experiences of many provinces and territories as well as OECD countries suggest that short-term solutions aimed at increasing the overall supply of physicians do not necessarily translate into improvements in their supply in these communities. Provincial and territorial governments have tried providing incentives to encourage physicians to move to rural areas through higher pay or other financial incentives. In other cases, governments have tried to limit where new physicians can practice in order to encourage more of them to work in rural communities.

Physicians typically object to measures that limit their ability to choose where they practice. Part of the answer certainly lies in increasing physicians’ exposure to rural settings as part of their education and training. With increased exposure to, and experience in, rural settings, the likelihood of graduating doctors wanting to practice in rural settings increases (BCMA 2002). Recent efforts by the Society of Rural Physicians of Canada and the College of Family Physicians of Canada to develop national curricula and guidelines are a step in the right direction. But there is much more to be done.

Differences in Approaches

Currently, there is no coherent national approach for addressing issues specific to rural communities. Provinces and territories are developing different ways to address the issues, but they are doing so in isolation, without enough attention to co-ordination or the overall picture.

A review of current approaches points to the following issues:

The lack of consensus on what “adequate” access should include - There is no consensus today on what constitutes adequate access and what services are most important for people to be able to access. One approach is to identify a basic core of services for different types of rural communities. This approach would clearly distinguish between the core services that would be available to people in their own communities and the services they would have to access from other centres. Key stakeholders, including health care providers and community members, should be involved in identifying and agreeing on the core services to be available in each community or region.

The need for effective linkages with larger centres - While some health care services can be delivered in smaller communities, some form of networked system that links those communities with urban centres is inevitable. Smaller communities simply cannot sustain a full range of services. Ontario’s “Rural and Northern Health Care Framework” (Ontario. Ministry of Health 1997) is an example of linkages between rural facilities, hospitals in regional centres and tertiary-care institutions in metropolitan areas, but it is by no means the only model. Similar linkages were proposed by Saskatchewan’s Commission on Medicare (Fyke 2001). Specialized services will continue to be concentrated in larger centres, but their linkages to rural communities should be improved.

The challenges of serving the smallest and most remote communities - These communities are the most difficult to serve because they have too few people to sustain anything but the most basic services, and even that can be difficult. Other countries face similar challenges and the models they have developed may be worth examining in Canada. For example, Australia developed a “Healthy Horizons” framework for improving access and health in small and remote communities (Australia 1999). This and similar models in other countries should be explored to see if they could be adapted to suit the unique Canadian context.

A focus on symptoms rather than causes - With few exceptions, strategies and programs have focused on how to deliver services and how to recruit and retain more health care providers. Although lack of access to health services as well as physicians and nurses are undoubtedly very serious problems, resolving these issues may not be enough to improve the health status of people in rural communities in a significant way. Instead, more emphasis needs to be placed on addressing the fundamental causes of the “rural health deficit.”

The predominance of “urban” approaches applied to rural communities - Many health care administrators, planners and providers rely on urban-focused approaches instead of developing alternative models to suit the unique circumstances of those communities. These primarily urban models make it difficult, if not impossible, for smaller communities to catch up to their urban counterparts. There is an increasing understanding that rural health problems are unlikely to be adequately addressed by mainstream programs alone (Humphreys et al. 2002). Unique rural health problems require urgent attention and unique rural conditions need to be taken into account in addressing those problems. The situation for health care providers is a case in point. Trends point to increasing specialization in skills and training. This might meet the needs of “high-tech” and research-intensive medicine in large hospitals in major urban centres, but the needs are almost the opposite for rural communities. They need a different kind of “specialist”  namely, well-trained and experienced generalist practitioners who “specialize” in delivering high quality primary health care in rural communities.

The lack of research - Policies and strategies for improving health and health care in smaller communities have not been based on solid evidence or research. Until recently, Canadian research on rural health issues has been piecemeal in nature and limited to small-scale projects. To make matters worse, despite the wealth of health-related data at the federal, provincial and territorial levels, most data collected or released are frequently not presented in a manner that supports meaningful rural health research and analysis (Pitblado et al. 1999). Furthermore, as with health research in general, there is little connection between decision makers and researchers. As a result, rural health policies, strategies, programs and practice have not been as effective as they could have been.

Setting a Clear Vision and Principles

Clearly, there are important challenges to address. The place to start is with a vision where Canadians residing in rural and remote regions and communities are as healthy as people living in metropolitan and other urban centres. This vision was echoed by Jose Amaujaq Kusugak at the Montreal public hearing who said, “I believe that … the success of our Health Care System as a whole will be judged not by the quality or service available in the best of urban facilities, but by the equality of service Canada can provide to its remote and northern communities” (Inuit Tapiriit Kanatami 2002).

This vision should guide all rural health initiatives including policy development, program planning, clinical practice, research, and health human resources development. It should be supported by the following principles:

Rural health initiatives should be designed to provide equity in both access to health care and in health outcomes.

No single strategy is appropriate for all communities. Unique approaches are needed to address the diverse health needs and different circumstances of different communities.

Both short-term, immediate issues (such as access to nurses and doctors) and long-term, more fundamental issues (such as economic and living conditions) must be addressed.

Health strategies should be focused on outcomes. Different approaches can be used as long as the objective is to improve health and access to health care.

Policies, strategies and programs should be based on evidence and informed by research. The outcomes of various approaches also need to be objectively assessed.

Strategies developed for urban centres may or may not be appropriate for rural communities. Rural communities may need to adapt urban-based approaches or may have to design their own strategies to meet their unique needs.

A truly national approach is needed to address the serious health challenges in rural health and to complement local or regional initiatives. Although many of these health issues have regional or local characteristics, they share common features and common problems  problems that require a national response. The provinces have constitutional responsibility for administering provincial health care systems and delivering health services to their citizens. However, the federal government could play a co-ordinating and facilitating role by working closely with the provinces and territories, as well as other stakeholders. Taken together, the following cluster of actions recommended in this and other chapters of this report will ensure that people in rural communities have better access to health care and better health.

Improving Access to Health Care

Expanding the Supply of Health Care Providers in Smaller Communities

RECOMMENDATION 30:

The Rural and Remote Access Fund should be used to attract and retain health care providers.

RECOMMENDATION 31:

A portion of the Rural and Remote Access Fund should be used to support innovative ways of expanding rural experiences for physicians, nurses and other health care providers as part of their education and training.

Improving access in smaller communities is tied directly to their ability to attract and retain health care providers. The immediate injection of additional funds from the Rural and Remote Access Fund should be directed to addressing this serious problem. Provinces and territories should decide which approaches are most appropriate for their communities, including the short-term option of using financial incentives to attract doctors and nurses to rural and remote communities.

A more promising solution over the longer term lies in the education and training of health care providers. As noted by the Association of Canadian Medical Colleges, a number of rural initiatives are taking place in Canadian medical schools (ACMC 2002). However, more work needs to be done to expand training opportunities for a range of health care professionals in rural and remote settings. Collaborative approaches to rural health practice are needed to get the maximum benefits from the skills of multidisciplinary teams and networks. More flexible use of health care providers should be encouraged, and training and support should be given to informal caregivers to support the role they play in rural settings.

Expanding Telehealth Approaches

RECOMMENDATION 32:

The Rural and Remote Access Fund should be used to support the expansion of telehealth approaches.

A number of innovative approaches can be used to improve access in smaller communities. Telehealth is a prime example. It uses information technologies to link patients and health care providers to a spectrum of services that can be brought together to provide higher quality care. It offers tremendous possibilities for overcoming the obstacles of distance and improving access to health care in rural communities (Pong 2002). People in rural and remote locations can be linked to family physicians, specialists and other health services in major centres. Health care providers can diagnose, treat and provide consultations at a distance. Patients and health care providers can have access to information about illnesses and the approach can also be used both for educating patients and providing professional development for health care providers in more remote locations. A variety of approaches can be used ranging from tele-triage to tele-education, and more recently, to tele-homecare. Several provinces have done extensive work on telehealth initiatives, particularly Newfoundland and Labrador.

Telehealth is particularly promising for northern Canada. The Honourable Edward Picco, Minister of Health and Social Services in Nunavut, noted that telehealth has the potential to be a lifesaver in Nunavut (Nunavut 2002). Ensuring access to health care is a daunting challenge when some people live in communities more than 2,000 km apart. Recognizing the potential benefits, the Government of Nunavut has signed agreements with the governments of Australia and Newfoundland and Labrador to share information and new developments in telehealth. In their view, increased use of telehealth technology will result both in cost savings and in improved health for territorial residents (Nunavut 2002).

Similarly, conditions in the north have required Yukoners to find innovative ways of providing effective and accessible health care. Telehealth applications have been used to facilitate increased mental health services, professional and continuing education, and family doctor visits. Most communities in the Yukon are a five- to six-hour drive away from Whitehorse and many are in locations that often are inaccessible by road or plane, especially in bad weather. There are instances where Yukon residents must rely on out-of-territory hospitals for specialized services. The cost of a single flight can be more than $10,000. Consequently, the costs of the Yukon medical travel plan have increased by 26% over the last five years (Yukon 2002).

The situation in the Northwest Territories is similar. People in the Northwest Territories face serious health issues including high rates of certain illnesses combined with a number of social factors that affect health. These challenges are exacerbated by the fact that health care services are stretched thin and access is seriously limited by the interplay of geographical expanse and limited health human resources and health care facilities. As a result, the government spends 6.5% of its budget for health and social services on transportation (NWT 2002).

With better evidence and evaluation, more effective choices can be made about the best use of telehealth technologies in specific settings. Actual evidence of the benefits of telehealth is minimal (Roine et al. 2001) and one study (Whitten et al. 2002, 1437) concluded that “there is presently no persuasive evidence about whether telemedicine represents a cost-effective means of delivering health care.” This is not to suggest that telehealth initiatives should not proceed. Rather, it points to a need for increased attention and effort in the evaluation of telehealth applications.

Because of the potential for telehealth to improve access to health care, the Rural and Remote Access Fund should be used to expand telehealth applications. Funds should be used to support both the necessary equipment within smaller communities as well as the necessary education, training and support to allow these technologies to be used and managed effectively. Early experience in the provinces is pointing to the immense value of telelearning and continuing education using information and communication technologies. Individual investments in telehealth should reflect the needs in individual communities and ensure that:

The necessary policies are in place for licensing health care providers to deliver health services at a distance (in particular, cross-jurisdictionally);

Privacy and security issues for patients have been adequately addressed;

Training and support is available to facilitate effective and efficient use of telehealth applications; and

The impact of telehealth applications on health outcomes in rural and remote communities is assessed.

Implementation of telehealth is hampered by the fact that many smaller communities do not have high-speed connections to the Internet. These connections depend on having access to technology known as basic broadband infrastructure. According to a recent report by the OECD (2001c), Canada ranks second in terms of overall broadband access, behind Korea, but ahead of Sweden and the United States. Despite this relatively high ranking, the National Broadband Task Force estimates that there are approximately 5,000 communities (79% of all Canadian communities) that fall into the “harder-to-serve” category. In their view, “the most revolutionary aspect of broadband is its potential to reduce … distance and time as cost factors  in economic activity and in providing public services” (Canada. Industry Canada 2001, 3). The Task Force recommended that broadband facilities and services be extended to all Canadian communities by 2004, with priority given to First Nations, Inuit, rural, and remote communities.

Priorities for future expansion of Canada’s broadband infrastructure should take central account of how telehealth care can improve access to health care in rural and remote communities across the country.

Improving Health

RECOMMENDATION 33:

The Rural and Remote Access Fund should be used to support innovative ways of delivering health care services to smaller communities and to improve the health of people in those communities.

In the past, innovative approaches have been funded primarily through pilot projects. The problem with this approach is that projects tend to be limited in both size and scope. Full-scale demonstration projects, supported by the Rural and Remote Access Fund, would allow provinces and territories to test not only innovative approaches to delivery of health care services and initiatives but also to explore the underlying causes of health problems in smaller communities.

Our experience in addressing a full range of factors and conditions that affect people’s health at the community or regional level has been limited. As a result, the relationship between health determinants, health behaviours and health status is largely unknown (Roussos and Fawcett 2000). Lower educational attainment, higher unemployment and poorer access to health care undoubtedly have an impact on the health status of people in smaller communities, but the specific impact of these factors has not been studied in a comprehensive way. Similarly, the impact of living in smaller communities on health behaviours and health status needs much more study. It is even less clear how adverse conditions in rural and remote communities can be ameliorated or reversed.

Multi-faceted approaches to strengthen social capital, enhance community resilience, build a viable economic base, and foster positive health behaviours are also limited. But there are some good models to follow such as the Canadian Heart Health Initiative, the Healthy Community Movement, and Better Beginnings Better Futures. These approaches take a broader approach, not just focusing on a particular illness but also including a number of factors that affect people’s health.

The population health demonstration projects envisioned in this report should be much larger in scale than previous pilot projects and involve different partners in different sectors of the economy and society in those communities. The objective is to find the best approaches to strengthen community resiliency, social capital and local capacity, improve healthy behaviours and lifestyles, and improve the overall health status of people in rural and remote communities.

The Rural and Remote Access Fund should support provinces, territories, communities and health authorities in developing and implementing a variety of models and approaches. For the Fund to be successful, a process must be in place to monitor, evaluate and disseminate the results of these demonstration projects, and, in particular, to highlight best practices and enable Canadian communities to learn from each other’s experiences. Funding should be based on demonstrated needs in communities, the use of innovative approaches to address those needs, and the potential of demonstration projects to result in overall improvements in the health of people in smaller communities across the country.

What Does This Mean for Canadians?

For people living in rural and remote communities, it means that some of their most pressing health needs will be addressed. It means that deliberate, decisive and immediate action can be taken to address severe shortages in health care providers in many smaller communities. It means the potential of new approaches like telehealth to literally bring health care to the doorstep of people in rural and remote communities can be realized. And over the longer term, it means the disparities between the health status of people in smaller communities and the rest of the Canadian population can be appreciably reduced.

CHAPTER 3: INFORMATION, EVIDENCE AND IDEAS

Building Canada ’s Health Research Knowledge Base

RECOMMENDATION 14:

Steps should be taken to bridge current knowledge gaps in applied policy areas, including rural and remote health, health human resources, health promotion, and pharmaceutical policy.

Taking the Next Steps to Expand Our Knowledge Base

Health research has played an essential role in the history of the public health system and will continue to do so in the future. With the variety of different funding agencies and bodies in place across the country, there are sufficient resources for institutes and their partners to conduct necessary research and evaluations, and disseminate results. In spite of this, there are a number of important problems and challenges within the health care system that currently receive insufficient attention within the scientific community, among governments and health researchers. On several occasions, the Commission was struck by the minimal amount of information available on issues as vital as rural and remote health and health care delivery, or interprofessional collaboration in primary health care settings. Health research challenges in these and other applied research areas require immediate attention and an associated investment of resources, both human and financial.

To this end, the Commission recommends that four Centres for Health Innovation for applied policy research should be created as soon as possible by the Canadian Institutes of Health Research. The federal government has increased CIHR funding substantially in recent years and appears sympathetic to CIHR’s desire to see that funding rise to $1 billion per year in the next few years. The Commission supports this direction. If this occurs, the CIHR should consider setting aside $20 million to fund the proposed Centres for Health Innovation, at a modest cost of $5 million for each centre per year. This cost is based upon the existing costs of the current policy-related institutes of the CIHR. The following four centres should be established:

Rural and remote health issues - The CIHR has already committed $5.2 million and the federal government has committed $1 million to research related to challenges faced by rural and remote communities. However, research to date has been conducted on a piecemeal basis. Rural health researchers have tended to work in relative isolation, just like the people and communities they study. A rural health agenda should be developed to address issues like health conditions and determinants, healthy behaviours, delivery and organization of services, and health status of people living in rural, remote and northern communities.”

CHAPTER 4: INVESTING IN HEALTH CARE PROVIDERS

Immediate Investments in People and Change

RECOMMENDATION 15:

A portion of the proposed Rural and Remote Access Fund, the Diagnostic Services Fund, the Primary Health Care Transfer, and the Home Care Transfer should be used to improve the supply and distribution of health care providers, encourage changes to their scopes and patterns of practice, and ensure that the best use is made of the mix of skills of different health care providers.

The health care system depends on people, and the ability of the system to move ahead with the reforms envisioned in this report will depend not only on having an adequate supply and the right distribution of health care providers, but also on their willingness to look at new approaches to how they deliver care.

There is little doubt that the fluctuations in funding for health care in the late 1980s and throughout the 1990s had some negative effects on Canada’s health workforce. As provincial, territorial and federal governments struggled to balance their books, “stop and go” funding negatively affected the supply of health care providers and seriously hampered attempts at long-term planning. This lack of continuity and predictability in funding has had a lasting impact on the delivery of health care services and the quality of work life for health care providers and professionals.

Immediate action needs to be taken on two fronts:

Improving the supply and distribution of health care providers in two priority areas - ensuring that rural and remote communities have the right mix of skilled health care providers to meet their needs, and improving the supply of specialized technicians to keep pace with increasing demands for diagnostic testing; and

Transforming the skills and roles of health care providers consistent with the overall directions for change outlined in this report.

Recommendations outlined in Chapter 2 propose a series of targeted funds and transfers to address priority areas and provide the transition to a new dedicated health transfer. Several of these funds, particularly the Rural and Remote Access Fund, the Diagnostic Services Fund, the Primary Health Care Transfer and the Home Care Transfer, should be used to address challenges in the supply, distribution and mix of skills of health care providers.

These additional funds should be specifically targeted to the most effective ways of addressing the most pressing problems. However, the Commission strongly feels that the additional funds should not become a target for increasing salary pressures from health care providers. There is a serious political risk to all parties - governments, health care providers and their organizations, and regional health authorities - if the bulk of the additional funds simply goes to pay more for the same level of service, the same access, and the same quality. This simply will not be acceptable to Canadians.

To address and resolve issues with today’s health workforce, it is important to go beyond what health care providers are paid and address the more complex but important issues of what they do, and how their roles must change to reflect new ways of delivering health care services.

Addressing Gaps in Supply and Distribution

Problems of rural communities in attracting and retaining an adequate supply of health care providers are well known and are discussed in Chapter 7. One of the major obstacles to improving access to essential health care services in rural and remote communities is the serious challenge these communities face in attracting and retaining health care providers. Over the next two years, expanding the supply of health care providers in these communities should be a major objective of the proposed Rural and Remote Access Fund. That may mean that a portion of that fund goes to creating incentives, financial and otherwise, to attract and retain the right mix of professional skills in those communities.

In the case of diagnostic services, information provided in Chapter 6 shows that Canada has fallen behind in its investment in diagnostic technology and, as a result, waiting times for access to MRI (magnetic resonance imaging) and CT (computed tomography) scans are increasing. However, purchasing the equipment is only one part of the solution. A portion of the proposed new Diagnostic Services Fund should be used to recruit and train the necessary supply of technologists and specialists needed to meet the demands and improve Canadians’ access to these essential services.